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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1P .601 E. Hazelton Ave. , Stockton, Calif. F <br /> Telephone: (209) X466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/a 77 r <br /> ' (Complete In Triplicate) <br /> Application is hereby made tothe San Joaquin Laca1 Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> quin Local Health District. <br /> County Ordinance No. 1862 andithe Rules and Regulations of the San Joa <br /> JOB ADDRESS T !/ CENSUS TRACT <br /> r Phone <br /> Owner's Name ;;11), <br /> City <br /> Address <br /> -� <br /> License � o/ 'hone <br /> Contractor's Name � Y � <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT J_ <br />'t Other "�/ .. <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 4!5:;�PIT PRIVY <br /> F <br /> SEWAGE DISPOSAL OL/SEEPAGE PITQf�� OTHER <br /> l <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL f CONSTRUCTION SPECIFICATIONS <br /> Industrial �" '�"�' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ? Driven Gauge of Casing ' <br /> Irrigation t Gravel Pack Depth of Grout Seal D <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical '; Surface Seal Inst fled B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / .'`State Work Done <br /> y Stage Work Done`, <br /> PUMP .REPAIR: I I <br /> DES-TRUCTION OF WELL: Well Diameter , <br /> Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to camP 1 Y with all laws and regulations of the an Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the, well and notify them before putting the .well in use. The above <br /> information is true to the best of, my knowledge and belief. I WILL CALL FO A GROUT INSPECTION <br /> i PRIOR TO GROUTING AND A FINAL INSPECTIO TITLE <br /> I SIGNED <br /> T PL REVERSE SIRE <br /> FOR DEPART NT USE ONLY <br /> PHASE I DATE '' D <br /> APPLICATION ACCEPTED BY J <br /> ADDITIONAL COMMENTS: PHASE IIIJFINAV INSPECTI!2-- <br /> N <br /> r PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY ✓ <br /> f <br /> F H 1426 Rev. 1-74 '` <br />